ONLINE AUTO CLAIM FORM

REPORT AN AUTO CLAIM
UMIALIK INSURANCE COMPANY
a member of the WESTERN NATIONAL INSURANCE GROUP

* Denotes required fields.

Umialik Policyholder Information

Type of Policy

Policy Number *

Umialik Policyholder's Name

Address

City

State

Zip

Contact Name *

Contact Phone *

Driver's Name *

Vehicle Description (Year, Make, Model) *

Person Submitting Claim is:

Email of Person Submitting Claim: *

Other Party Information

Name of Other Party

Address

City

State

Zip

Contact Name

Contact Phone

Driver's Name

Vehicle Description (Year, Make, Model)

Additional Other Parties and/or Witnesses

If you have additional information about the other party, please enter it in the text box below.

Loss Information

Date of Loss *

Loss Location

Location of Damaged Property *

Description of Accident or Loss *

Other Vehicles & Property Damage Information

Were there any other vehicles damaged?

Yes

If yes, how many?

If yes, please provide details.

Was there damage to property other than vehicles?

Yes

If yes, please provide details.

Injury Information

Was anyone injured?

Yes

If yes, how many?

Name of First Injured

Description of Injury

Telephone Number

Name of Second Injured

Description of Injury

Telephone Number

Name of Third Injured

Description of Injury

Telephone Number

Name of Fourth Injured

Description of Injury

Telephone Number

If more than four injuries, please list below.

ONLINE AUTO CLAIM FORM

Umialik Policyholder Information

Other Party Information

Additional Other Parties and/or Witnesses

Loss Information

Other Vehicles & Property Damage Information

Injury Information

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